welcome, intro & goals - ase foundation...unclassified pacific partnership 2016 welcome, intro...

UNCLASSIFIED PACIFIC PARTNERSHIP 2016

Welcome, Intro & GoalsPP16 Imaging ConferenceBicol Hospital, Legaspi City, Philippines

July 2016

David Adams, ACS, RCS, RDCS, FASEDuke University Medical Center


Echocardiography

2

The Anatomy Lesson of Dr. Tulp by Rembrandt


SMEE


Proposed Echo SMEE• This SMEE will be an educational collaboration between the Navy,

American Society of Echo Foundation (ASEF) and the Philippine Society of Echocardiography (PSE) at the Bicol Hospital.

• Navy Cardiologist CDR David Krause• The ASEF - approved this as one of three 2016 global health initiatives.

– Team Leader: David Adams, Duke Cardiac Sonographer– ASEF Staff: Andrea Van Hoever, VP of Research – additional ASE cardiologists & sonographers

• PSE President Dr. Edwin Tucay and Dr. Thad Ciocson from Bicol Hospital

• Format: 2 day seminar with lectures on current updates in echo and hands on training of echo techniques scanning patients provided by Dr. Ciocson. The emphasis will be on screening for congenital and rheumatic heart disease.

4


USNS Mercy


Countries in PP16


PP16 in Legazpi


A long, long time ago


Goals• Learn from each other


Day 1

10


Day 2

11


Goals• Learn from each other• Ask questions• Be flexible• Take care of our patients• Questions?


Optimizing Echo / Hemodynamics

PP16 Imaging ConferenceBicol Hospital, Legaspi City, Philippines

July 2016



Optimizing Echo / Hidden Things in the HeartPP16 Imaging ConferenceBicol Hospital, Legaspi City, Philippines

July 2016



Todays Talk• Optimizing the Echo Images• Ultrasound Machine Controls

–Why it’s important–Good vs Bad


Why its important• Operator dependent technique• Image quality varies between pts• Quality affects measurements • And diagnosis


Fig 2-17

The Challenge


Knobology• The science of which knob or

control to adjust and what it does to an ultrasound image.


Goals• When to use what controls• Optimizing the 2D images


• Depth• Sector size• Gain• TGC• Frequency• Harmonics• Gray scale

Controls: 2D Images


2 Common Mistakes• Over gaining

– destroys resolution


Important controls

1


2D Gain

Too Low Too High


2D Gain

Just Right


Color Doppler Gain

Good Too High


TGC• Time Gain Control (Compensation)• Evens out the overall image brightness• Suppresses the strong near field echoes• Boosts the weaker far field echoes


Bad TGC Settings


Image Quality• Resolution• Target acquisition• Display (gray scale)


Transducer frequency• Lower frequency

– better penetration (targets)– worse resolution

• Higher frequency– worse penetration (targets)– better resolution


Resolution

2.5 MHz 4.0 MHz


Harmonics• Fundamental

–Transmit & receive at the same frequency

• Harmonics– Transmit & receive at different

frequencies


Fundamental Imaging


Harmonic Imaging


Harmonics• Why is it important?• Harmonics causes the leaflets to

be thicker.• For RHD and measuring the

leaflets – turn Harmonics off!!


Harmonics

Off On


2 Common Mistakes

• Over gaining• Foreshortened LV


Foreshortened


Apical Four - ChamberImage true apex

Maximize RV dimension

No aorta

No coronary sinus


Systematic Approach

• Optimal gray scale• Adjust the monitor• Image in view / depth• TGC – even gray throughout• Overall gain – do not over gain!!!


Todays Talk• Optimizing the Echo Images• Ultrasound Machine Controls

–Why it’s important–Good vs Bad

• Hidden Things in the Heart


The Heart• 4 chambers & 4 valves (hopefully)• Other things we see:

– Catheters / devices – Clots / cysts– Vegetation's– Tumors– Bullets / knives– Artifacts– Normal Variants


The Problem• Normal Variants can be

confusing• Mistaken for pathology• Can lead to unnecessary tests or

even cardiac surgery• The Solution• Know detailed anatomy • Common things are common!


Normal VariantsEustachian valve

Dumbell IAS Q-tip signCoumadin ridge Valve excrescences

Atrial septal aneurysmsFalse chords / tendonsPectinate muscles

Chiari network Eustachian ridge

Crista terminalisTrabeculationsLigament of Marshall

Moderator Band

Thebesian ValveLipomatous Hypertrophy


Confusing!!!!!!

Dumbell IAS


Goals for Today

• Review normal anatomy• Review normal variants• Show examples• Become less confused • The more you see the

more you know


Right Atrium• Crista Terminalis• Eustachian Valve• Thebesian Valve• Chiari Network• IAS Lipomatous Hypertrophy• IAS Aneurysm


Crista Terminalis– Ridge between the

smooth & trabeculated RA walls

– When prominent it may be mistaken for a RA mass

From A Sonographer’s Guide textbook by Bonita Anderson


Crista terminalis


Crista terminalis– Do sweeps– Shows connections

& the extent of anatomy


Crista terminalis


Eustachian Valve– Valve of the IVC– Directs flow to the

LA in fetal circulation

– Best seen in the subcostal IVC view

– Can be prominent or undulating



Eustachian Valve– Can be confused

with intracardiacthrombus

– Or complicate IVC cannulation


Thebesian Valve– Valve of the

coronary sinus– Well known to the

EP docs for biV lead placement

– Best seen in the parasternal RVIT view



Thebesian Valve– Valve of the

coronary sinus– Well known to the

EP docs for BIV lead placement

– Best seen in the parasternal RVIT view


Chiari Network– Mobile

filamentous strands in the RA

– Random motion– Has been

associated with PFO’s & IAS aneurysms


Chiari network


Hyperlipomatous IAS

• Lipomatous hypertrophy of the IAS– Benign process– “Dumbbell” appearance

(Echo term)– Fossa ovalis is spared

(lack of fat cells)


Hyperlipomatous IAS


IAS Aneurysm– Idiopathic or may

develop due to high atrial pressures

– Thin and hypermobile movement of the central IAS

– Some say > 15 mm– Associated with

PFOs & may be prone to thrombus formation


IASA


IASA Gross Pathology


Left Atrium• LAA & Pectinate Muscle• Ligament of Marshall• Transverse Sinus


LA Appendage– Contractile– Trabeculated –

pectinate muscles– Variable anatomy– 1-5 lobes


Major LAA Types

From JAFIB LA Appendage Morphology by Ajay VallakatiCase Western Reserve University


Ligament of Marshall

– Atrial tissue between the LUPV & LAA

– Also called the Q-tip, Warfarin or Coumadin ridge

– Has been mistaken for thrombus


Transverse sinus– Potential pericardial

space between the LA & AO root

– Could be mistaken for an abscess


Right Ventricle

• Trabeculations• Moderator

Band

From Atlas of Human Anatomy by Frank Netter


RV Trabeculations– The RV is normally

more heavily trabeculated than the LV

– Difficult to see small, layered thrombi


Moderator Band

– Septomarginaltrabecula

– Helps define the anatomic RV in CHD


Moderator Bands


Moderator Band

From Diagnostic Atlas of the Heart by Hurst & Alpert

– Septomarginaltrabecula

– Helps define the anatomic RV in CHD

– Contains conduction fibers to the anterior pap muscle


Left Ventricle• False Tendons• Trabeculations• Lambl’s

Excrescences

From Atlas of Human Anatomy by Frank Netter


False Tendons– Usually towards the

LV apex– Also called accessory

chords, LV chords, aberrant bands or “heart strings”

– Known to cause a murmur

– May mimic thrombus or the edge of a tumor


False Tendons (2D & 3D)


LV Chord


LV Trabeculations

–May be more prominent in remodeled ventricles (LVH)


RV & LV Trabeculations


Lambl’s Excrescences

– Small, mobile filamentous strands coming off the AoVleaflets.

– May mimic valvular vegetations so must be put in a clinical context


Conclusions• Know cardiac anatomy

– All of it!!• Know the echo characteristics• Remember that ultrasound

beams diverge and have width• Do sweeps to make connections• Common things are common!


The End

welcome, intro & goals - ase foundation...unclassified pacific partnership 2016 welcome, intro...

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